Improved HealtH Care and Its ImpaCt on CHIldren: an exploratIon of penda HealtH

60 Pages·2013·1.08 MB·English

Child impaCt CaCsHeI lsdt uImdypa 6C: tim Cparsoev setdU hdeya 6lth Care
Improved HealtH Care
and Its ImpaCt on CHIldren:
an exploratIon of
penda HealtH
By Heather Esper, Ted London, and Yaquta Kanchwala
providing access to quality primary and preventive
health care (immunizations, routine health exams,
and health education) can increase quality of life
for low-income women and their families. this case
examines the impacts a for-profit enterprise in
Kenya providing primary health care services to the
Base of the pyramid (Bop)i, has on children and
pregnant women and how these impacts can be
enhanced. penda Health provides primary care,
both curative and preventive care, to low- and
middle-income families and specializes in women’s
health care. It provides breast cancer and cervical
cancer screenings, the full range of family planning visit informed us of a change in financial resources
services including counseling, and treatment for available for patients’ children: if parents replace
women’s reproductive system diseases. the government clinics with penda as their primary health
outpatient clinic aims to deliver a positive patient care provider, they spend more per visit. However,
experience by offering evidence-based, depending on the situation, parents could be spending
standardized, high-quality primary health care in a less overall, due to penda’s accurate diagnosis
friendly environment. resulting in lower costs related to fewer return visits
to the clinic (e.g. saved transportation and income
We studied the impacts on children age eight and from missed work). If penda’s customers previously
under and on pregnant women, resulting from used more expensive private health care providers,
penda’s services. the main impacts we found on increased savings could benefit their children if spent
penda’s customers’ children are improvements in on their health care, nutritional and schooling needs.
health due to high-quality, affordable diagnoses Improvements in the health of pregnant women
and treatment by penda, their parents’ improved increase their ability to care for themselves, the fetus,
health due to the same services, and their and ultimately their newborn child. We also found
parents’ beneficial actions based on the health that penda’s focus on preventive health care and
care education they receive from penda. penda’s screenings may allow parents to live healthier lives
friendly service makes patients comfortable to and provide more support to children.
ask any health care-related questions. In addition,
children who attend schools that partner with an additional benefit is that patients share the health
penda have access to high-quality health care information they learn from penda with others in the
education and services. Improved health also broader Bop community, including non-customers;
reduces school absenteeism and increases the parents forward penda's smses and children tell
ability to spend more time on homework. our site other children. Children of penda’s employees can
also benefit from the additional income their parents
i the Bop—estimated at approximately 4 billion people—is the
socio-economic segment that primarily lives in and operates earn when spent on their needs. the ongoing health
micro-enterprises in the informal economy, and generally has an
training that employees receive, including first-
annual per capita income of less than 3,000 Usd in purchasing
power parity (ppp). aid, improves their children’s health accordingly.

next Generation: Child Impact series • december 2013
Child impaCt Case study 6: improved health Care
aBoUt tHe aUtHors
HeatHer esper is the Program Manager of Impact Assessment at the William Davidson Institute at the
University of Michigan and an editor and writer for NextBillion.net. Her research centers on exploring the
poverty reduction contributions of businesses and organizations serving low-income markets. Esper works
with these ventures to identify, measure, analyze and leverage their impacts in order to develop strategies
to better meet the needs of their stakeholders and further contribute to reducing poverty. She holds a
Master’s degree in Public Health and a Bachelor of Science degree in Global Health from the University of
Michigan.
ted london is a Senior Research Fellow and the Director of the Base of the Pyramid Initiative at the
William Davidson Institute and is a faculty member of the University of Michigan’s Ross School of Business.
His research focuses on designing enterprise strategies and poverty alleviation approaches for low-
income markets, assessing poverty reduction outcomes of business ventures, and developing capabilities
for cross-sector collaborations. He has published numerous articles, reports, and teaching cases, sits on
several advisory boards, and shares his research in venues around the globe.
yaqUta KanCHWala is a Research Associate at the William Davidson Institute at the University
of Michigan. She has worked in multiple sectors: agricultural value chains, agritech, food security,
microfinance, and access to energy. Her experiences include developing social enterprise growth strategies
and conducting rapid impact assessments. She holds a Bachelor of Science in Engineering from Rutgers
University and a Master of International Affairs from Columbia University’s School of International and
Public Affairs.
aCKnoWledGements
This case was made possible with the support of the Bernard van Leer Foundation. In particular, we
would like to thank BvLF’s Michael Feigelson for his guidance and continued support. Many thanks
to Penda, in particular Stephanie Koczela, Beatrice Ngoche, Nick Sowden, Sheezaad Zainulbhai, and
Scollastica Kananu, for their assistance in providing information and access to key stakeholders. We
would like to thank WDI’s Healthcare Research Specialist, Lisa Smith, for her efforts in helping us shape
recommendations and clarifying any questions related to the health care sector in East Africa. We would
also like to thank WDI’s Research Assistant Navjot Singh for his assistance in re-creating the graphs
presented in this case and conducting research on pricing in the Kenyan health care system, WDI's Mary
Lowe for her research assistance, and Research Assistants Annalise Latting and Arianne Tjio for their copy-
editing efforts.
CItatIon
Esper, H., London, T., and Kanchwala, Y. (2013). Improved Health Care and its Impact on Children: An
Exploration of Penda Health. Child Impact Case Study No. 6. Ann Arbor: The William Davidson Institute
©Copyright 2013 William Davidson Institute at the University of Michigan.
The William Davidson Institute at the University of Michigan and the
Bernard van Leer Foundation encourage fair use with the exception of
modifications of this material. Proper citation is requested. This publication
may not be resold for profit.
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Child impaCt Case study 6: improved health Care
aBoUt tHe serIes
UNICEF states that poverty reduction should start with young children (UNICEF. 2000. Poverty Reduction
Begins with Children). The first years of life have a large influence on an individual’s long-term well-being.
Poverty at an early age can cause lifelong damage to children’s future and perpetuate the cycle of poverty
across generations. Thus early childhood interventions offer an opportune time to influence the poverty
cycle. The effects of poverty can be passed on to children through their parents; improving the well-being
of parents therefore can also enhance the well-being of their children.
This series was funded by the Bernard van Leer Foundation, a private philanthropic organization focused
on improving the lives of children from birth to age eight. The goal of these cases is to gain a greater
understanding of the ways in which businesses in emerging markets impact young children’s lives and the
potential to optimize impact on children. We also hope that these case studies will influence development
and impact investing leaders to include metrics related to young children in their measurement systems.
In tHIs serIes
Improved HoUsInG and Its ImpaCt on CHIldren: an exploratIon of Cemex’s patrImonIo
Hoy
Patrimonio Hoy provides construction materials to low-income consumers in Mexico, Nicaragua, Costa Rica,
Colombia and the Dominican Republic through a 70-week payment plan that allows its customers to build
onto their current homes or build new homes room by room.
Improved sanItatIon and Its ImpaCt on CHIldren: an exploratIon of sanerGy
Sanergy builds 250 USD modular sanitation facilities called Fresh Life Toilets (FLTs) in Mukuru, a large slum
in Nairobi, Kenya, and sells them to local entrepreneurs for about 588 USD. Franchisees receive business
management and operations training and earn revenues by charging customers 0.04-0.06 USD per use.
dIversIfIed farm InCome, marKet faCIlItatIon and tHeIr ImpaCt on CHIldren: an
exploratIon of Honey Care afrICa
Honey Care Africa (HCA) of Kenya supplies smallholder farmers with beehives and harvest management
services. HCA guarantees a market for the beekeeper’s honey at fair trade prices, providing a steady source
of income.
aCCess to Clean lIGHtInG and Its ImpaCt on CHIldren: an exploratIon of solaraId’s
sUnnymoney
SunnyMoney sells pico-solar products to BoP communities with limited access to electricity in Tanzania,
Malawi, Kenya, and Zambia. It markets the lamps through schools and existing entrepreneur networks.
Improved InCome staBIlIty, traInInG, marKet faCIlItatIon and tHeIr ImpaCt on CHIldren:
an exploratIon of vIlla andIna
Villa Andina of Peru produces high-quality agro-industrial food products through its work with local
smallholder farmers. The venture trains framers in organic cultivation techniques and provides guaranteed
payment for the crops produced.
Improved HealtH Care and Its ImpaCt on CHIldren: an exploratIon of penda HealtH
Penda Health provides high-quality, evidence-based, standardized primary care, both curative and
preventative, to low- and middle-income families in Kenya while also specializing in women’s health care.
BUIldInG a sCalaBle BUsIness WItH small-Holder farmers In Kenya: Honey Care's
BeeKeepInG model
This teaching case study examines Honey Care Africa’s transition from obligating farmers to maintain their
own hives to providing hive management services. Readers will explore strategies to reduce side-selling
and opportunities to generate greater impacts on farmers’ families, in particular young children. The case
can be found on GlobaLens.com.
Also included in the series is a summary article, Focusing on the Next Generation: An Exploration of
Enterprise Poverty Impacts on Children, that aggregates findings across the above six ventures.
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Child impaCt Case study 6: improved health Care
Contents
executive summary ...................................................................................................................................................6
Company Background ..............................................................................................................................................9
The Genesis of Penda Health .................................................................................................................................................9
Health Care in Middle and Low-Income Markets ..........................................................................................................11
Penda's Business Model .........................................................................................................................................................12
Health Care Services ......................................................................................................................................................12
Pricing ..................................................................................................................................................................................13
Advertising .........................................................................................................................................................................14
Quality Control .................................................................................................................................................................16
The Penda Difference .....................................................................................................................................................16
Organizational Structure ..............................................................................................................................................18
Competition ................................................................................................................................................................................21
focusing on Impacts on Children age eight and Under ...................................................................................24
Framework and Methodology ............................................................................................................................................24
Methodological Limitations ...........................................................................................................................................5
Impact Findings .......................................................................................................................................................................26
Impacts on Customers’ Children and Child Patients .........................................................................................28
Impacts on Children in the Broader Community ................................................................................................33
Impacts on BoP Staffs' Children ...............................................................................................................................33
opportunities for Greater Impact .......................................................................................................................35
Enhance Positive Impacts ....................................................................................................................................................35
Reduce Negative Impacts .....................................................................................................................................................37
Increase Penetration into Current Markets ....................................................................................................................38
Expand to New Populations and Markets ......................................................................................................................40
Capturing Impacts ....................................................................................................................................................41
Moving Toward a Systematic Impact Assessment ......................................................................................................41
Conclusion ...............................................................................................................................................................43
appendicies .............................................................................................................................................................44
Appendix A: Additional Impacts on Customers’ Children and Child Patients. ................................................44
Appendix B: Additional Impacts on Staff of Penda Health’s Children................................................................46
Appendix C: Impacts of Family Planning Services……………………..…………………………………… ..................................47
Appendix D: Additional Impact Assessment Suggestions ......................................................................................52
endnotes ...................................................................................................................................................................55
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Child impaCt Case study 6: improved health Care
taBles, fIGUres, and Boxes
table 1: substantial Impact on Children (penda’s patients or Children of penda’s patients)……… ...............7
figure 1: map of Kitengela…………………………………………………………………………………………………… ........................9
Box 1: minute Clinic…………………………………………………………………………………………………………………… ................12
Box 2: Head-to-toe services………………………………………………………………………………………………………… ............12
figure 2: penda's Business model……………………………………………………………………………………… ........................18
Box 3: a Child’s perspective…………………………………………………………………………………………… ...........................19
Box 4: a Child’s perspective…………………………………………………………………………………… ...................................20
table 2: penda as Compared to its direct Competitors……………………..……………………………… .......................21
table 3: other Health Care Competitors in the Kenyan landscape……………………………………… ....................22
Box 5: portrait of penda's Bop market……………………………………………………………………………… .........................23
figure 3: direct and Indirect Impacts on Children………………………………………………………………………… ..........24
table 4: description of primary Interview respondents………………………………………… ....................................25
Box 6: a Child’s perspective…………..…………………………………………………………………… .......................................26
table 5: summary of Impacts on Children age 8 and Under across penda Health’s stakeholders……… ..27
table 6: summary of Impacts of family planning services on patients’ Children age 8 and Under……… .32
Box 7: exploration of Individuals Who Choose not to Use penda's sources ...............................................34
table 7: opportunities to enhance positive Impacts…………………………………………………………… .....................35
table 8: opportunities to decrease negative Impacts……………………………………………………………… ...............37
table 9: opportunities to Increase market penetration…………………………………………………………… .................38
table 10: average Cost of transportation to penda’s Clinic via different modes………………………..… ..........39
table 11: opportunities to expand to new populations and new markets……………………………………… ........40
table 12: suggested Impacts to measure and potential questions……………………………… ..............................52
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Child impaCt Case study 6: improved health Care
exeCUtIve sUmmary
According to the World Health Organization (WHO), approximately 6.9 million children under the age
of five died in 2011—nearly 19,000 per day and almost 800 every hour. Of these, nearly 80% of deaths
occurred in 25 countries, and about half in only five countries: India, Nigeria, Democratic Republic of
the Congo, Pakistan and China.1 In 2010, 58% of under-five deaths were caused by infectious diseases-
pneumonia, diarrhea, and malaria accounted for more than one third of all under-five deaths. “The majority
of these deaths can be prevented by simple, low-cost interventions, such as immunization, appropriate
use of antibiotics, zinc and oral rehydration therapy, exclusive breastfeeding for infants up to six months of
age, insecticide treated bed nets (ITN), and anti-malarials.”2
Providing access to high-quality primary and preventive health care (immunizations, routine health exams)
can increase the quality of life for low-income women and their families at the Base of the Pyramid (BoP).
The BoP—estimated at approximately four billion people—is the socio-economic segment that primarily
lives and operates micro-enterprises in the informal
economy, and generally has an annual per capita income of
less than 3,000 USD in purchasing power parity (PPP). We stakeholders
explore the impacts of providing access to primary health
patients
care on children age eight and younger and on pregnant
Penda specializes in women’s
women living in BoP communities by studying the influence health; it also provides primary
of Penda Health (henceforth shortened to Penda) on its curative and preventive health care
patients. In this specific case, access focuses on availability, services to children and men.
affordability, and patient adoption via patient empowerment local staff
and health care education. This definition of access is Penda hires individuals from the
adapted from Frost and Reich’s access to health care communities it serves.
framework, which consists of four A’s: architecture (policies)
Broader Community
that allows for access, affordability, availability, and adoption Individuals who do not have a
(patient health education and acceptability of treatment). relationship with Penda other than
living near Penda activities.
Penda provides primary care, both curative and preventive,
to low- and middle-income families and specializes in
women’s health care. It provides breast cancer and cervical
cancer screenings, the full range of family planning services including counseling, and treatment for
women’s reproductive system diseases. The outpatient clinic aims to deliver a positive patient experience
by offering evidence-based, standardized, high-quality primary health care in a friendly environment.
Penda opened its first clinic in the industrial town of Kitengela, Kenya, in February 2012, an industrial
town outside of Nairobi. The average cost per visit at Penda is approximately 5-7.5 USD as compared to
the average cost of 40-50 USD at high-quality private clinics and no fees at government clinics. Penda
provides the local population with an alternative to free or nearly free government clinics, which often
have very long wait times (sometimes even two to three days), to self-provider clinics, many of which do
not have qualified practitioners and/or equipment, and to traditional healers who practice non-evidence-
based medicine.
We gained an initial understanding of the impacts that access to improved health care have on our
target population through a literature review and interviews with thought leaders in the private, primary
health-care provider space. We then investigated Penda’s impacts on our target population across three
dimensions of well-being--economic, capability, and relationship--through in-depth qualitative interviews
with key Penda stakeholders in Kitengela, Kenya. Both direct impacts on children as well as indirect
impacts on children through their parents and the environment were assessed across the following
stakeholders (see sidebar)
We found that Penda has the greatest impacts on its patients’ children and child patients (presented
in table 1). Based on conversations with Penda’s patients we learned that priority is given to the most
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Child impaCt Case study 6: improved health Care
vulnerable — children age five and under.3 We expect that school-age children, those three and older, are
more likely to become ill due to increased contact with other children. We also learned that spending on
health care is not prioritized by gender, but rather by severity of sickness.4
table 1: substantial Impacts on Children (penda’s patients or
Children of penda’s patients)
Changes in Wealth: Changes in financial resources available for child’s well-
being due to changes in household expenditure on health care (increased
expenditure if parents previously went to government clinics, decreased
economic expenditures if earlier visits to government clinics resulted in incorrect
Well-Being diagnosis, and decreased expenditure if parents previously visited expensive
private clinics). As a result of their improved health from Penda’s care,
healthier parents miss fewer days of work due to illness and hence earn more
income that could be spent on their children’s needs.
Improved physical Health: Children’s physical health improves from their
parents’ access to high-quality, affordable health care, in addition to their
parents’ beneficial actions based on health education they receive through
the venture. At Penda, children benefit from receiving the right diagnosis and
medicine often resulting in shorter duration and severity of illness. Penda’s
low cost services increase the frequency of patients’ visits, resulting in earlier
detection of illness. Children’s health is also impacted through the improved
health of their parents, from reduced exposure to infectious diseases and
health risk factors. In particular, improvements in the health of pregnant
Capability
women affect their ability to care for themselves, the fetus, and ultimately
Well-Being
their newborn child.
Penda’s friendly service makes patients more comfortable to ask questions
and develop trusting relations with the clinical officers. Parents also learn new
health information about how to care for their children via Penda’s information
distribution channels such as SMS. The instructions that partnering school’s
employees receive through Penda training also improves children’s health.
Improved education: As a result of their improved health (reduced sick-day
absenteeism), children spend more time in school and on their homework.
Increased support: Children benefit from the increased quality and quantity
relationship
of time the family spends together when parents and children enjoy improved
Well-Being
health outcomes.
In addition to patients’ children, Penda positively impacts the children of its staff members and people
within the broader community. The children of Penda’s staff benefit from the additional income their
parents earn, when their parents contribute toward their immediate needs like food, clothing, and
educational opportunities. The ongoing health training Penda staff members receive improves their
children’s health accordingly. Children of the broader community are impacted, indirectly, through contact
with patients (or their parents’ contact with patients): patients share health information they receive from
Penda with others in the community.
We visited Penda in the ninth month of its operations and were unable to fully study Penda’s impacts from
family planning services. During our literature review, we found multiple impacts on children (both direct
and indirect), including negative impacts but we cannot fully state how, when, and what impacts will apply
in the Penda context (see summary of impacts in table 5 and a detailed discussion, including sources used
in appendix C.)
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Child impaCt Case study 6: improved health Care
Based on the likely outcomes that Penda has on children and pregnant women, we identify opportunities
for the venture to enhance, deepen, and expand its impacts:
• penda should explore methods to increase preventive health care visits among children as a major
trend in Kenya is to seek medical services only when ill. In addition, penda should explore methods
to attract more children overall to the clinic by focusing efforts on attracting their mothers along with
making the clinic more child-friendly
• penda should explore creative methods and marketing to increase visits by pregnant women to
ensure healthy development of the fetus
• penda should explore leveraging children in partner schools as informal health ambassadors to
spread health care messages to the wider community
• penda should explore what are the negative impacts of family planning services on women who seek
them at the venture
• penda can consider introducing necessary medical equipment and services to attend to all health
needs of patients and their families
• penda should explore the impact of providing free services at events that are run either by penda or
by partner organizations
• penda should explore ways to connect potential patients from the Bop with health care financing
Beyond these key recommendations, we also offer guidance on conducting impact assessments in a
systematic and manageable manner.
note: Due to similarity in impacts across the six cases and in an attempt to be concise, we only include
secondary research supporting and further exploring impacts in the first case study of this series—
Patrimonio Hoy. Also, please note that since these cases were developed over the course of 2012-2013, a
number of our recommendations to enhance positive and mitigate negative impacts for the venture, have
been implemented since we visited the venture. As such, please visit the enterprise's website for more
information on their latest practices.
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Child impaCt Case study 6: improved health Care
Company BaCKGroUnd
tHe GenesIs of penda HealtH

Penda Health (henceforth called Penda), a primary health care provider to low- and middle-income
families, was formed in mid-2011 by Beatrice Ngoche, Stephanie Koczela, and Nicholas Sowden, each of
whom have experience working in Kenya with vulnerable populations. Penda opened its first outpatient
clinic in February 2012 in Kitengela, Kenya (see figure 1), an industrial town 35 kilometers from Nairobi
that has a workforce of 20,000, 85% of which are women.5 The five-room, ground-floor clinic on the
town’s main road, that remains open on weekends, saw 620 paying patients in December 2012, 570 in
January 2013, and a record 819 in February 2013. Penda aims to maintain its clinical patient load to a
minimum of 720 patients a month (24 per day), in order to break-even. In addition to providing curative
and preventive health care solutions, Penda specializes in women’s reproductive and sexual health: it
provides breast cancer and cervical cancer screenings, the full range of family planning services including
counseling, and treatment for women’s reproductive system diseases.
Penda won the 2012 Entrepreneur of the Year award from BiD Network and is part of the following
international health consortiums:
• International Partnership for Innovative Healthcare Delivery (IPIHD): a program to support innovators
and entrepreneurs in scaling innovative health care delivery solutions6
• Center for Health Market Innovations (CHMI): promoting policies and practices that improve privately
delivered health care for the poor in low- and middle-income countries7
figure 1: map of Kitengela
AFRICA
KENYA
Rift
Valley
Nairobi
Kitengela
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Child impaCt Case study 6: improved health Care
Penda was created to fulfill
unmet health needs in the
local market: during Penda’s
market research phase, the
management team found a
severe lack of quality and
affordable options for most
Kenyans, including cases were
people were misdiagnosed,
met unqualified doctors who
had old equipment and drugs
and were sometimes rude to
their patients.8 As Ngoche
explained, “many Kenyans
were treated poorly and felt
stigmatized by the system,”
especially regarding women’s
health issues.9
Penda’s reception and waiting area includes seating and a television to keep “I had just attended too
patients busy. many funerals, people dying
from completely preventable
causes and treatable diseases, standing at the sides of graves and holding the babies of parents who had
died from basic infections that are treatable in other parts of the world,” said Koczela, describing what
prompted her and her colleagues to open Penda’s Kitengela clinic.10 Penda’s goal is to “transform health
care in East Africa by building a chain of outpatient health clinics that offer evidence-based, standardized,
primary health care and unparalleled member experience by clinical officers, at surprisingly affordable
rates,” said Sowden.11
Informational material placed in Penda’s reception and waiting area.
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